Claims Specialist - Workers Compensation

Old Republic Commercial Risk; Roseville (CA); On-site; USD 60,000 - 80,000; Full time

Job summary

Old Republic Commercial Risk is seeking an experienced Claims professional in California (Roseville) to independently investigate, evaluate and resolve high-complexity Workers’ Compensation claims. You will administer and resolve high-risk claims with attention to statutory and policy guidelines.

Responsibilities include determining coverage and compensability, managing reserves, negotiating settlements within authority, and coordinating with PMA nurses on return-to-work strategies while

Qualifications

• Bachelor's degree or four+ years of equivalent insurance experience.
• CA experience required in the role.
• AIC designation or similar preferred.
• License required or ability to obtain within 90 days of employment.
• Familiarity with Workers' Compensation regulations and terminology.

Responsibilities

• Investigate and resolve assigned claims with minimal supervision.
• Determine coverage, compensability, potential for subrogation, and second injury fund where applicable.
• Alert supervisor and SIU to potentially suspect claims.
• Ensure timely denial or payment of benefits per jurisdictional requirements.
• Establish reserves with documented rationale and adjust as needed.
• Negotiate settlements within granted authority.
• Develop and execute action plans for case resolution including medical and disability management.
• Collaborate with PMA nurses to implement return-to-work strategies.
• Select and manage service vendors to balance expenses and loss outcomes.
• Maintain knowledge of jurisdictional requirements and case law for states served.
• Communicate effectively with internal/external parties on claims and accounts.
• Provide high-quality customer service during reviews, meetings, and sessions.
• Authorize treatment per PMA Managed Care protocols.
• Suggest panel provider information per state statutes.

Skills

Organizational skills

Critical thinking

Verbal communication

Written communication

Customer service

Education

Bachelor's degree or 4+ years experience

AIC designation or similar

Tools

MS Office

Job description

As a member of our Claims team, utilize your knowledge of Workers Compensation Claims to independently investigate, evaluate and resolve assigned claims of a more complex nature in order to achieve appropriate outcomes. In this position you will administer and resolve highest risk management expectations claims in a timely manner in accordance with legal statues, policy provisions, and company guidelines.

Responsibilities

• Promptly investigates all assigned claims with minimal supervision, including those of a more complex nature
• Determines coverage, compensability, potential for subrogation recovery, and second injury fund (when applicable)
• Alerts Supervisor and Special Investigations Unit to potentially suspect claims
• Ensures timely denial or payment of benefits in accordance with jurisdictional requirements
• Within granted authority, establishes appropriate reserves with documented rationale, maintains and adjusts reserves over the life of the claim to reflect changes in exposure
• Negotiates claims settlements within granted authority
• Establishes and implements appropriate action plans for case resolution including medical and disability management, litigation management, negotiation and disposition
• Works collaboratively with PMA nurse professionals to develop and execute return to work strategies
• Selects and manages service vendors to achieve appropriate balance between allocated expense and loss outcome
• Maintains a working knowledge of jurisdictional requirements and applicable case law for each state serviced
• Demonstrates technical proficiency through timely, consistent execution of best claim practices
• Communicates effectively, verbally and in writing with internal and external parties on a wide variety of claims and account issues
• Provides a high degree of customer service to clients, including face to face interactions during claims reviews, stewardship meetings and similar account-specific sessions
• Authorizes treatment based on the practiced protocols established by statute or the PMA Managed Care department
• Assists PMA clients by suggesting panel provider information in accordance with applicable state statutes.
• Demonstrate commitment to Company’s Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards and laws applicable to job responsibilities in the performance of work.

Requirements

• Bachelor's degree and/or four or more years of equivalent work experience required in an insurance related industry required
• CA experience is required
• Associate in Claims (AIC) Designation or similar professional designation desired
• License required or ability to obtain license within 90 days of employment in mandated states
• Familiarity with medical terminology and/or Workers' Compensation
• Working knowledge of Workers Compensation regulations, preferably jurisdiction-specific
• Strong organizational skills with demonstrated ability to work independently and deal effectively with multiple tasks simultaneously
• Proven critical thinking skills that demonstrate analysis/judgment and sound decision making with focus on attention to details
• Strong verbal, written communication skills and customer service skills gained through previous work experience
• Computer literacy, including working knowledge of MS Office Product Suite, i.e. Word, Excel, PowerPoint
• Ability to travel for business purposes, approximately less than 10%.
• Salary expectations - $60,000 - $80,000